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CMS released the 2014 Mid-Year Quality and Resource Use Reports (MYQRURs) to physician solo practitioners and groups of physicians nationwide, including solo practitioners and groups with physicians who participated in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization (ACO) model, or the Comprehensive Primary Care (CPC) initiative in 2014. The 2014 MYQRURs were made available for informational purposes and contain information on a subset of the measures used to calculate the 2016 Value Modifier. This MLN ConnectsNational Provider Call will provide an overview of the 2014 MYQRUR and explain how to interpret and use the information in the report. Learn more about the reports on the MYQRUR web page.

The call will be more meaningful if you have your MYQRUR in front of you to follow along. Visit the How to Obtain a QRUR web page and access your report prior to the call.

During this MLN Connects National Provider Call, CMS subject matter experts provide an overview and update to the Medicare Shared Savings Program Accountable Care Organization (ACO) application process for the performance period beginning January 1, 2016. The Shared Savings Program Application web page has important information, dates, and materials on the application process, which call participants are encouraged to review prior to the call. A question and answer session will follow the presentation.

Agenda:

Medicare Shared Savings Program application process

Required templates

Participant List

Narratives and uploads

Lessons learned

Target Audience: Potential 2016 Shared Savings Program applicants who submitted a Notice of Intent to Apply.

During this MLN ConnectsNational Provider Call, CMS subject matter experts will provide updates for the National Partnership and Quality Assurance and Performance Improvement (QAPI). Additionally, a nursing home will discuss steps taken to achieve antipsychotic medication reduction in their facility, and Indiana University will present information about evidence-based dementia care training. A question and answer session will follow the presentations.

The National Partnership to Improve Dementia Care in Nursing Homes and QAPIare partnering on MLN Connects Calls to broaden discussions related to quality of life, quality of care, and safety issues.The National Partnership was developed to improve dementia care in nursing homes through the use of individualized, comprehensive care approaches to reduce the use of unnecessary antipsychotic medications. QAPI standards expand the level and scope of quality activities to ensure that facilities continuously identify and correct quality deficiencies and sustain performance improvement.

During this MLN Connects National Provider Call, CMS subject matter experts will discuss the new Hospice Item Set (HIS) Manual (V1.02). This call will focus on updates that were made to the HIS Manual from V1.01 to V1.02 and provide clarifications of HIS definitions and expectations for use. Providers should review V1.02, which will be available on the HIS web page prior to the call.

Agenda:

Background and overview of the Hospice Quality Reporting Program (HQRP)

It’s not too late to get ready for ICD-10 implementation on October 1, 2015. During this MLN ConnectsNational Provider Call, CMS subject matter experts will present strategies and resources to help you prepare. Also, learn about ICD-10-PCS Section X for new technologies, which will be used by hospitals. A question and answer session will follow the presentations.

CMS will host an MLN ConnectsNational Provider Call on the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP), a pay-for-performance initiative that ties a facility's quality scores to a payment percentage reduction over the course of a Payment Year (PY). On July 15, a preliminary PY 2016 Performance Score Report (PSR) will be available for ESRD facilities. Find out how to access, review, and submit a formal inquiry about your report by the August 15 deadline. A question and answer session will follow the presentation.

Agenda:

How to access and review your facility PSR

How CMS calculated ESRD QIP performance scores using quality data

What the performance scores means for PY 2016 payment rates

When and where to ask questions regarding PSR, including how to submit one formal inquiry

Duty and responsibility to make ESRD QIP performance data transparent to patients

CMS will host an MLN ConnectsNational Provider Call on the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP), a pay-for-performance quality initiative that ties a facility's quality scores to a payment percentage reduction over the course of a Payment Year (PY). This call will focus on the upcoming ESRD Prospective Payment System (PPS) proposed rule, which would operationalize the ESRD QIP in PY 2019. A question and answer session will follow the presentation.

The audio recording and transcriptare now available for the May 12 call — Medicare Acute Care Quality and Reporting Programs. More information is available on the call detail web page. This call provided an overview of all Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs.

To help you prepare for the transition to ICD-10, CMS offers acknowledgement testing for current direct submitters (providers and clearinghouses) to test with the Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) contractor anytime up to the October 1, 2015, implementation date.

CMS previously conducted three successful acknowledgement testing weeks in March 2014, November 2014, and March 2015. These acknowledgement testing weeks give submitters access to real-time help desk support and allow CMS to analyze testing data. Mark your calendar for the final acknowledgement testing week on June 1 through 5, 2015.

Note:MLN Matters® Special Edition Article SE1501 explains the differences between acknowledgement and end-to-end testing with Medicare. For acknowledgement testing, all electronic submitters are encouraged to participate, even if you submit claims through a clearinghouse.

How to participate:

Information is available on your MAC website or through your clearinghouse (if you use a clearinghouse to submit claims to Medicare). Any provider who submits claims electronically can participate in acknowledgement testing.

What you can expect during testing:

Test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected in the system

Test claims will be subject to all current front-end edits, including edits for valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and codes, including Healthcare Common Procedure Coding System (HCPCS) and place of service

Testing will not confirm claim payment or produce a Remittance Advice (RA)

MACs and CEDI will be staffed to handle increased call volume during this week

Testing tips:

Make sure test files have the "T" in the ISA15 field to indicate the file is a test file

Send ICD-10 coded test claims that closely resemble the claims that you currently submit

Use valid submitter ID, NPI, and PTAN combinations

Use current dates of service on test claims (i.e. October 1, 2014 through June 1, 2015)

CMS will host a Special Open Door Forum to provide Home Health Agencies (HHAs) and other interested parties with additional information on the new “Pay-for-Reporting Performance Requirement.” The first 12-month reporting period for the new Quality Assessments Only (QAO) measure begins July 1; HHA compliance will potentially affect the Annual Payment Update (APU) for CY 2017. See the announcement for more information and participation instructions.

CMS will host a one-hour Virtual Office Hour session via WebEx to discuss the Physician Compare website. During this session, CMS will answer stakeholders’ questions about Physician Compare and public reporting. Anyone interested in participating can register by sending an email to the Physician Compare support team. You can also include up to three questions (one primary and two secondary) with your registration or send them separately. All questions must be received by 5pm ET on Monday, June 15. For more information about Physician Compare, visit the Physician Compare Initiative web page.

Subject matter experts from CMS and the Office of the National Coordinator for Health Information Technology (ONC) provided an overview of the CMS Stage 3 and ONC 2015 Certification Criteria proposed rules.

If you are interested in applying for participation in the Medicare Shared Savings Program for the January 1, 2016, program start date, you must submit a Notice of Intent to Apply by Friday, May 29, 2015, 8pm ET. For more information about the application process, visit the Shared Savings Program Application web page, and register for the MLN Connects® National Provider Call on June 9.

Groups have 4 weeks to register to participate in the 2015 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) via the Physician Value - Physician Quality Reporting System (PV-PQRS) Registration System. PQRS GPRO is an option available to groups with 2 or more eligible professionals (EPs). Groups must meet the satisfactory reporting criteria through the PQRS GPRO in order to avoid the -2.0% CY 2017 PQRS payment adjustment. More information is available on the PQRS Payment Adjustment Information web page.

Physicians in groups of all sizes and physician solo practitioners are subject to the Value Modifier in 2017, based on performance in 2015. Under the Value Modifier, these physicians and groups must meet the criteria to avoid the downward payment adjustment under PQRS in order to avoid an additional automatic downward adjustment under the Value Modifier and qualify for adjustments based on their quality performance. Satisfactorily reporting via a PQRS GPRO is one of the ways groups can avoid automatic downward adjustments and qualify for performance-based payment incentives under the Value Modifier. See What Physicians Need to do in 2015 for the 2017 VM on the Value Modifier web page for more information.

Groups can participate in the PQRS program for the 2015 performance period by selecting one of the GPRO reporting mechanisms between April 1, 2015, and June 30, 2015, at 11:59pm ET:

Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS Survey via a CMS-certified Survey Vendor (as a supplement to another GPRO reporting mechanism). See CAHPS for PQRS Made Simple for complete details.

Physician groups with 2 or more EPs that choose not to register, must ensure that at least 50% of the EPs in the group meet the criteria to avoid the 2017 PQRS payment adjustment as individuals in order for the group to avoid the automatic 2017 Value Modifier downward payment adjustment (-2.0% or -4.0% depending on the group’s size).

The Registration System can be accessed using a valid Individuals Authorized Access to the CMS Computer Services (IACS) account. CMS strongly encourage groups to obtain an IACS account and register by June 26, since registration will close on June 30, 2015. CMS will be transitioning to a new Enterprise Identity Management (EIDM) system in the upcoming months; therefore, all registrations must be received before the deadline. Stay tuned for more information and resources in the coming weeks and months about the EIDM. In the meantime, please ensure that your IACS account is active, current, and you’re able to log in. This will help ensure a smoother transition to EIDM.Instructions for obtaining an IACS account with the correct role are provided on the PQRS GPRO Registration web page. Instructions for registering to participate in the 2015 PQRS GPRO are provided in the 2015 PQRS GPRO Registration Guide.

On May 26, HHS Secretary Sylvia M. Burwell announced awards of $112 million to regional cooperatives to work with about 5,000 primary care professionals in 12 states to improve the heart health of their nearly 8 million patients. Heart disease is the leading cause of death for men and women in the United States. EvidenceNOW: Advancing Heart Health in Primary Care will help primary care practices in both urban and rural communities use the latest evidence to encourage better care, smarter spending, and healthier people.

The EvidenceNOW initiative establishes seven regional cooperatives composed of multidisciplinary teams of experts that will each provide quality improvement services to up to 300 small primary care practices. In addition, an eighth awardee will receive a grant to conduct an independent external evaluation of the overall EvidenceNOW initiative. The seven implementation grants will run for three years, and the evaluation grant for four years.

For more information:

Agency for Healthcare Research and Quality’s EvidenceNOW initiative, including details on each of the grantees and cooperatives

CMS released guidance for Long Term Care (LTC) facilities, including nursing facilities and skilled nursing facilities, regarding facility actions to disenroll beneficiaries from Medicare Advantage plans or Medicare-Medicaid plans (MMPs) that serve Medicare-Medicaid (dually eligible) enrollees as part of the Financial Alignment Initiative. CMS continues to see an unacceptable practice of LTC facilities disenrolling beneficiaries from these plans without the beneficiary’s or the representative’s knowledge or complete understanding. Only a Medicare beneficiary, the beneficiary’s legal representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment or voluntary disenrollment from a Medicare plan. Please review this guidance to ensure you are complying with federal regulations and guidance concerning changes to facility residents’ Medicare plan coverage.

I have CMNs for patients that contain ICD-9 diagnosis codes. Do I need to submit new CMNs with ICD-10 codes for claims submitted after the transition to ICD-10?

Answer:

CMS is not requiring suppliers to submit updated Certificates of Medical Necessity (CMNs) for claims submitted on or after the ICD-10 implementation date of October 1, 2015; however, these claims must contain a valid ICD-10 diagnosis code. CMNs created after the transition to ICD-10 must use ICD-10 codes. Suppliers should ensure that the diagnosis code(s) billed on the claim are supported by documentation in the medical record.

Question:

After ICD-10 implementation, how should pharmacies handle prescriptions with ICD-9 codes that were written prior to the implementation date?

Answer:

When filling prescriptions that were written prior to the ICD-10 implementation date of October 1, 2015, pharmacies have the option to use the reimbursement mappings posted on the 2015 ICD-10-CM and GEMs and 2015 ICD-10 PCS and GEMs web pages to translate ICD–9 codes into ICD–10. New prescriptions written after the transition to ICD-10 must use ICD-10 codes.

Medicare requires the use of ICD-10 codes on home health (HH) claims and Requests for Anticipated Payment (RAPs) with a “Through” date on or after October 1, 2015. Since HH claims are submitted for a 60-day payment episode, there may be cases where an episode spans October 1. In these cases, the RAP for an episode will be submitted using ICD-9 codes and the corresponding claim will be submitted using ICD-10 codes. For more information, see MLN Matters® Article SE1410.

Medicare does not require ICD-10 coding of these episodes in advance of the ICD-10 implementation date. Home Health Agencies should determine whether identifying the ICD-10 codes in advance will benefit them.

The April 2015 version of the Integrated Outpatient Code Editor (IOCE) has been updated to include both ICD-9-CM and ICD-10-CM codes on the OCE Quarterly Release Files web page. The July 2015 IOCE release will also include both ICD-9-CM and ICD-10-CM. The final version of the IOCE that utilizes ICD-10-CM is scheduled for release in August 2015.

On October 1, 2015, ICD-10-CM will replace the ICD-9-CM code set currently used by providers for reporting diagnosis codes. Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, including CPT/HCPCS modifiers for physician services. While ICD-10-CM codes have expanded detail, including specification of laterality for some conditions, providers will continue to follow CPT and CMS guidance in reporting CPT/HCPCS modifiers for laterality.

As a result of the recent passing of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, Medicare Administrative Contractors (MACs) will be mass adjusting all Federally Qualified Health Center (FQHC) claims billed under the Prospective Payment System (PPS) with dates of service on or after April 1, 2015, through May 3, 2015.

The “Medically Unlikely Edits Compliant” Podcast (ICN 909210) was released and is now available. This podcast, based on MLN Matters® Article SE1422, clarifies that while claims filed using noncompliant coding for bilateral surgical procedures may have been paid in the past, Medically Unlikely Edit (MUE) changes may now render those claim lines unpayable.

The “Medicare Appeals Process” Fact Sheet (ICN 006562) was revised and is now available in downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources.